Crosswalk for Templates: IMD, ICF IID, PRTF, Clinic, and Physician

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Overview

ICFIID
PRTF
IMD
Clinic
Physician

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Sheet 1: ICFIID

Sheet	Template Section	Location in Original Version	Location in Current Version	Variable Number	Change since last OMB approval January 2021
Required State Input - ICF	Data	A2	A2	001	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - ICF	Tooltip	A2	A2	001	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - ICF	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Tooltip	B2	B2	002	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration begin date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - ICF	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Tooltip	C2	C2	003	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration end date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - ICF	Data	Column B	Column B	100	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - ICF	Tooltip	Column B	Column B	100	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - ICF	Tooltip	Column C	Column C	101	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration rate year. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are 4 digit numeric strings representing the year in the format YYYY.
Required State Input - ICF	Tooltip	Column D	Column D	102	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the service type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is ICF.
Required State Input - ICF	Tooltip	Column E	Column E	104	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is "Cost."
Required State Input - ICF	Data	Column F	Column F	105	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - ICF	Tooltip	Column F	Column F	105	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the Other State Provider ID Number. A data validation error is triggered when duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E13	E13	105	Updated text for Data Dictionary Long Description: State provider ID number that is not a Medicaid (MCD) ID number (if applicable).
Required State Input - ICF	Data	Column I	Column I	107	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - ICF	Tooltip	Column I	Column I	107	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the State-specific Provider ID (Medicaid ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E15	E15	107	Updated text for Data Dictionary Long Description: Medicaid (MCD) ID number.
Required State Input - ICF	Data	Column J	Column J	108	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - ICF	Tooltip	Column J	Column J	108	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Provider Name. A data validation error is triggered when this variable is missing data or duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - ICF	Data	Column G	Column G	109	Added conditional formatting to flag duplicates of variable 109.
Required State Input - ICF	Tooltip	Column G	Column G	109	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: National Provider ID (NPI). A data validation error is triggered when duplicate values exist for this variable.
Required State Input - ICF	Tooltip	Column K	Column K	110	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the ownership category type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are: Private, NSGO, and SGO.
Required State Input - ICF	Data	Column H	Column H	112	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - ICF	Tooltip	Column H	Column H	112	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Certification Number (Medicare ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E20	E20	112	Updated text for Data Dictionary Long Description: Medicare (MCR) ID number. In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC".
Required State Input - ICF	Data	D2	D2	116	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B22	B22	116	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - ICF	Tooltip	D2	D2	116	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Retrospective or Prospective. A demonstration is retrospective if submitted on or after the start of the demonstration period. A demonstration is prospective if submitted prior to the start of the demonstration period.
Required State Input - ICF	Data	E2	E2	117	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B23	B23	117	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - ICF	Tooltip	E2	E2	117	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the State Plan Amendment Number. Expected format: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Required State Input - ICF	Data	Column M	Column M	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Tooltip	Column M	Column M	200.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Cost Report Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E24	E24	200.1	Updated text for Data Dictionary Long Description: MCR rate Cost report begin date of the data provided that is are used to calculate the UPL.
Required State Input - ICF	Data	Column N	Column N	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Tooltip	Column N	Column N	200.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Cost Report End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E25	E25	200.2	Updated text for Data Dictionary Long Description: MCR rate Cost report end date of the data provided that is are used to calculate the UPL.
Required State Input - ICF	Data	Column O	Column O	211	Added conditional formatting to flag variable 211 in ICF as red if it is missing values.
Required State Input - ICF	Tooltip	Column O	Column O	211	Added the following tool tip to the data entry cells in the required state input tab: Required. Enter Medicare Per Diem. A data validation error is triggered when this variable is missing or has an invalid value. Valid values for this field are numeric characters.
Data Dictionary	N/A	E27	E27	211	Updated text for Data Dictionary Long Description: Per diem cost or Medicare (MCR) equivalent rate used to calculate the UPL from the period specified in Variables 200.1 and 200.2.
Required State Input - ICF	Tooltip	Column P	Column P	212.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustments to Medicare Per Diem #1. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E28	E28	212.1	Updated text for Data Dictionary Long Description: Adjustment to Medicare (MCR) Per Diem (if used) to account for services not included in the MCR SNF =Skilled Nursing Facility (SNF) rate but reimbursed by the Medicaid program (e.g., leave of absence days).
Required State Input - ICF	Tooltip	Column Q	Column Q	212.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustments to Medicare Per Diem #2. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E29	E29	212.2	Updated text for Data Dictionary Long Description: Adjustment to Medicare (MCR) Per Diem (if used) to account for services not included in the MCR Skilled Nursing Facility (SNF) rate but reimbursed by the Medicaid program (e.g., leave of absence days).
Required State Input - ICF	Tooltip	Column L	Column L	224	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Source of UPL or Cost Report Data. A data validation error is triggered when this variable is missing data. Example values for this variable include Physician Fee Schedule, Cost Report, Cost-to-Charge ratio, Payment-to-Charge Ratio, etc.
Required State Input - ICF	Tooltip	Column R	Column R	300.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E35	E35	300.1	Updated text for Data Dictionary Long Description: Beginning date of base year Medicaid (MCD) days (note: should match MCR Cost Report data period).
Required State Input - ICF	Tooltip	Column S	Column S	300.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E36	E36	300.2	Updated text for Data Dictionary Long Description: End date of base year Medicaid (MCD) days (note: should match MCR Cost Report data period).
Required State Input - ICF	Tooltip	Column AC	Column AC	307	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Medicaid Inflation Factor Type.
Data Dictionary	N/A	E38	E38	307	Updated text for Data Dictionary Long Description: Description of Medicaid payment/cost trend factor used to reflect changes in the Medicaid program between the base and current UPL Demonstration rate year periods (e.g., Market Basket).
Required State Input - ICF	Tooltip	Column AD	Column AD	308	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E39	E39	308	Updated text for Data Dictionary Long Description: Cumulative Medicaid payment/cost trend factor used to reflect changes in the Medicaid program between the base (midpoint of Variable 300.1 and Variable 300.2) and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point approach").
Required State Input - ICF	Tooltip	Column AE	Column AE	309	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustment to Medicaid Payments. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E40	E40	309	Updated text for Data Dictionary Long Description: Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the Medicaid program between the base (midpoint of variable 300.1 and variable 300.2) and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point
Required State Input - ICF	Tooltip	Column T	Column T	310	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Days. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E41	E41	310	Updated text for Data Dictionary Long Description: Medicaid (MCD) days from time period specified in Variables 300.1 and 300.2, used in calculating the UPL for the base period.
Required State Input - ICF	Tooltip	Column U	Column U	311.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E42	E42	311.1	Updated text for Data Dictionary Long Description: Beginning date of Medicaid (MCD) rates used to determine total MCD payments for purposes of comparing to the UPL (these dates may differ from period used for days).
Required State Input - ICF	Tooltip	Column V	Column V	311.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Data Dictionary	N/A	E43	E43	311.2	Updated text for Data Dictionary Long Description: End date of Medicaid (MCD) rates used to determine total MCD payments for purposes of comparing to the UPL (these dates may differ from period used for days).
Required State Input - ICF	Tooltip	Column W	Column W	312	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Regular Payment Per Diem. A data validation error is triggered when this variable is missing data.
ICF	N/A	Column X	Column X	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Required State Input - ICF	N/A	Column W	Column W	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	D44	D44	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	E44	E44	312	Updated text for Data Dictionary Long Description: Medicaid (MCD) base payments per diem applicable to the period specified in Variables 311.1 and 311.2.
Required State Input - ICF	Tooltip	Column X	Column X	313.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem. A data validation error is triggered when this variable is missing data.
Required State Input - ICF	Tooltip	Column Y	Column Y	313.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (GME/Training). A data validation error is triggered when this variable is missing data.
Required State Input - ICF	Tooltip	Column Z	Column Z	313.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (Other). A data validation error is triggered when this variable is missing data.
Required State Input - ICF	Tooltip	Column AA	Column AA	314.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #1. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E48	E48	314.1	Updated text for Data Dictionary Long Description: Adjustment to Medicaid (MCD) base payments per diem to account for services paid separately outside of the Medicaid ICF/IID rate, but reimbursed under Medicare (MCR) (e.g., drugs, therapy, lab, radiology).
Required State Input - ICF	Tooltip	Column AB	Column AB	314.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #2. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E49	E49	314.2	Updated text for Data Dictionary Long Description: Adjustment to Medicaid (MCD) base payments per diem to account for services paid separately outside of the Medicaid ICF/IID rate, but reimbursed under Medicare (MCR) (e.g., drugs, therapy, lab, radiology).
Data Dictionary	N/A	E54	E54	400	Updated text for Data Dictionary Long Description: Calculated Inflated UPL Per Diem based on instructions provided in spreadsheet (e.g., for cost-based demonstration: base year Adjusted Total Cost Per Diem (Variable 215) * UPL Inflation Factor (Variable 405)).
Required State Input - ICF	Tooltip	Column AH	Column AH	401	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Provider Tax Cost. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E55	E55	401	Updated text for Data Dictionary Long Description: For cost-based demonstrations, Medicaid (MCD) provider tax costs can be added to the UPL separately. Report here only the Medicaid portion of the cost of the provider tax.
Required State Input - ICF	Tooltip	Column AI	Column AI	402	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustments to the UPL Amount. A data validation error is triggered when this variable is missing data.
Required State Input - ICF	Tooltip	Column AF	Column AF	404	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter UPL Inflation Factor Type.
Data Dictionary	N/A	E58	E58	404	Updated text for Data Dictionary Long Description: Description of cumulative payment/cost trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the UPL Demonstration rate year (e.g., Market Basket).
Required State Input - ICF	Tooltip	Column AG	Column AG	405	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E59	E59	405	Updated text for Data Dictionary Long Description: Cumulative payment/cost trend factor used to inflate the Total Cost Per Diem (Variable 215) Calculated MCD UPL Per Diem from the base year (midpoint of Variables 200.1 and 200.2) to the UPL Demonstration rate year (note: 1.00 = no change) (use "mid-point to mid-point approach
Required State Input - ICF	Tooltip	Column AJ	Column AJ	408	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Adjustment to the UPL Gap. A data validation error is triggered when this variable is missing data.
Required State Input - ICF	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column M	Column M	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column R	Column R	300.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column U	Column U	311.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column N	Column N	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column S	Column S	300.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - ICF	Data	Column V	Column V	311.2	Applied conditional formatting if begin dates are not before end dates.
Overview & Instructions	Sheet	A5	A5	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – ICF. Updated Overview & Instructions tab to reflect new tab name.
Required State Input - ICF	Sheet	N/A	N/A	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – ICF. Updated Overview & Instructions tab to reflect new tab name.
State Attestation	Data	N/A	N/A	N/A	Modified state data entry fields (dates, names, etc.) on the “State Attestation” tab to be fillable entry cells rather than hard underlined spaces that move/shift as you enter data.
UPL Demonstration Summary	All	N/A	N/A	N/A	Updated UPL Demonstration Summary tab to incorporate Medicaid days in the calculations for per diem data.

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Sheet 2: PRTF

Sheet	Template Section	Location in Original Version	Location in Current Version	Variable Number	Change since last OMB approval January 2021
Required State Input - PRTF	Data	A2	A2	001	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - PRTF	Tooltip	A2	A2	001	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - PRTF	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Tooltip	B2	B2	002	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration begin date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Tooltip	C2	C2	003	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration end date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Data	Column B	Column B	100	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - PRTF	Tooltip	Column B	Column B	100	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - PRTF	Tooltip	Column C	Column C	101	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration rate year. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are 4 digit numeric strings representing the year in the format YYYY.
Required State Input - PRTF	Tooltip	Column D	Column D	102	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the service type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is PRTF.
Required State Input - PRTF	Tooltip	Column E	Column E	104	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable include "Cost," "Payment," and "Charge."
Required State Input - PRTF	Data	Column F	Column F	105	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PRTF	Tooltip	Column F	Column F	105	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the Other State Provider ID Number. A data validation error is triggered when duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PRTF	Data	Column I	Column I	107	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PRTF	Tooltip	Column I	Column I	107	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the State-specific Provider ID (Medicaid ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PRTF	Data	Column J	Column J	108	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PRTF	Tooltip	Column J	Column J	108	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Provider Name. A data validation error is triggered when this variable is missing data or duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PRTF	Data	Column G	Column G	109	Added conditional formatting to flag duplicates of variable 109.
Required State Input - PRTF	Tooltip	Column G	Column G	109	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: National Provider ID (NPI). A data validation error is triggered when duplicate values exist for this variable.
Required State Input - PRTF	Tooltip	Column K	Column K	110	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the ownership category type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are: Private, NSGO, and SGO.
Required State Input - PRTF	Data	Column H	Column H	112	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PRTF	Tooltip	Column H	Column H	112	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Certification Number (Medicare ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PRTF	Data	D2	D2	116	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B22	B22	116	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - PRTF	Tooltip	D2	D2	116	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Retrospective or Prospective. A demonstration is retrospective if submitted on or after the start of the demonstration period. A demonstration is prospective if submitted prior to the start of the demonstration period.
Required State Input - PRTF	Data	E2	E2	117	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B23	B23	117	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - PRTF	Tooltip	E2	E2	117	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the State Plan Amendment Number. Expected format: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Required State Input - PRTF	Data	Column L	Column L	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Tooltip	Column L	Column L	200.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Begin Date for Charge, Cost, or Payment Data. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
PRTF	Label	Column L	Column L	200.1	Required State Input/PRTF output tab: Changed name from “Begin Date for Cost, Charge or Payment Data” to “Begin Date for Charge, Cost, or Payment Data”.
Required State Input - PRTF	Label	Column L	Column L	200.1	Required State Input/PRTF output tab: Changed name from “Begin Date for Cost, Charge or Payment Data” to “Begin Date for Charge, Cost, or Payment Data”.
Data Dictionary	N/A	D24	D24	200.1	Data Dictionary: Short Description: Changed from “Begin Date for Cost, Charge or Payment Data” to “Begin Date for Charge, Cost, or Payment Data”
Data Dictionary	N/A	E24	E24	200.1	Data Dictionary: Long Description: Changed from “Begin date of cost, charge or payment data provided that is used to calculate the UPL” to “Begin date of charge, cost, or payment data provided that are used to calculate the UPL.”.
Required State Input - PRTF	Data	Column M	Column M	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Tooltip	Column M	Column M	200.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the End Date for Charge, Cost, or Payment Data. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
PRTF	Label	Column M	Column M	200.2	Required State Input/PRTF output tab: Changed name from “Ending Date for Cost, Charge or Payment Data” to “End Date for Charge, Cost, or Payment Data”.
Required State Input - PRTF	Label	Column M	Column M	200.2	Required State Input/PRTF output tab: Changed name from “Ending Date for Cost, Charge or Payment Data” to “End Date for Charge, Cost, or Payment Data”.
Data Dictionary	N/A	D25	D25	200.2	Data Dictionary: Short Description: Changed from “Ending Date for Cost, Charge or Payment Data” to “End Date for Charge, Cost, or Payment data”.
Data Dictionary	N/A	E25	E25	200.2	Data Dictionary: Long Description: Changed from “End date of cost, charge or payment data provided that is used to calculate the UPL” to “End date of charge, cost, or payment data provided that are used to calculate the UPL.”.
Required State Input - PRTF	Tooltip	Column O	Column O	212.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustments to Per Diem Cost, Charge, or Payment. A data validation error is triggered when this variable is missing data.
PRTF	Label	Column O	Column O	212.3	Required State Input/PRTF output tab: Changed name from “Adjustments to Per Diem Cost, Charge or Payment” to “Adjustments to Per Diem Charge, Cost, or Payment”.
Required State Input - PRTF	Label	Column O	Column O	212.3	Required State Input/PRTF output tab: Changed name from “Adjustments to Per Diem Cost, Charge or Payment” to “Adjustments to Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	D27	D27	212.3	Data Dictionary: Short Description: Changed from “Adjustments to Per Diem Cost, Charge or Payment” to “Adjustments to the Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	E27	E27	212.3	Data Dictionary: Long Description: Changed from “Adjustment to per diem cost, charge or payment” to “Adjustments to per diem charge, cost, or payment.”.
PRTF	Label	Column P	Column P	215	PRTF output tab: Changed name from “Total Per Diem Cost, Charge or Payment” to “Total Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	D29	D29	215	Data Dictionary: Short Description: Changed from “Total Per Diem Cost, Charge or Payment” to “Total Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	E29	E29	215	Data Dictionary: Long Description: Changed from “Calculated as Per Diem UPL Amount (Variable 223) + Adjustments to Per Diem Amount (Variable 213.3)” to “Calculated as Per Diem Charge, Cost, or Payment (Variable 223) + Adjustments to Per Diem Charge, Cost, or Payment (Variable 212.3).”.
Required State Input - PRTF	Tooltip	Column N	Column N	223	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Per Diem Charge, Cost, or Payment. A data validation error is triggered when this variable is missing data.
PRTF	Label	Column N	Column N	223	Required State Input/PRTF output tab: Changed name from “Per Diem Cost, Charge or Payment” to “Per Diem Charge, Cost, or Payment”.
Required State Input - PRTF	Label	Column N	Column N	223	Required State Input/PRTF output tab: Changed name from “Per Diem Cost, Charge or Payment” to “Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	D31	D31	223	Data Dictionary: Short Description: Changed from “Per Diem Cost, Charge or Payment” to “Per Diem Charge, Cost, or Payment”.
Data Dictionary	N/A	E31	E31	223	Data Dictionary: Long Description: Changed from “Per diem cost, charge or payment amount used to calculate the UPL from the period specified in Variables 200 and 201” to “Per diem charge, cost, or payment amount used to calculate the UPL from the period specified in Variables 200.1 and 200.2.”
Required State Input - PRTF	Tooltip	Column P	Column P	300.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Tooltip	Column Q	Column Q	300.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Tooltip	Column AA	Column AA	307	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Medicaid Inflation Factor Type.
Required State Input - PRTF	Tooltip	Column AB	Column AB	308	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Required State Input - PRTF	Tooltip	Column AC	Column AC	309	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustment to Medicaid Payments. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column R	Column R	310	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Days. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column S	Column S	311.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Tooltip	Column T	Column T	311.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PRTF	Tooltip	Column U	Column U	312	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Regular Payment Per Diem. A data validation error is triggered when this variable is missing data.
PRTF	Label	Column V	Column V	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Required State Input - PRTF	Label	Column U	Column U	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	D42	D42	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Required State Input - PRTF	Tooltip	Column V	Column V	313.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column W	Column W	313.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (GME/Training). A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column X	Column X	313.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (Other). A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column Y	Column Y	314.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #1. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column Z	Column Z	314.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #2. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column AF	Column AF	402	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustments to the UPL Amount. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Tooltip	Column AD	Column AD	404	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter UPL Inflation Factor Type.
Required State Input - PRTF	Tooltip	Column AE	Column AE	405	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Required State Input - PRTF	Tooltip	Column AG	Column AG	408	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Adjustment to the UPL Gap. A data validation error is triggered when this variable is missing data.
Required State Input - PRTF	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column L	Column L	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column P	Column P	300.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column S	Column S	311.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column M	Column M	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column Q	Column Q	300.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PRTF	Data	Column T	Column T	311.2	Applied conditional formatting if begin dates are not before end dates.
Overview & Instructions	Sheet	A5	A5	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – PRTF. Updated Overview & Instructions tab to reflect new tab name.
Required State Input - PRTF	Sheet	N/A	N/A	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – PRTF. Updated Overview & Instructions tab to reflect new tab name.
State Attestation	Data	N/A	N/A	N/A	Modified state data entry fields (dates, names, etc.) on the “State Attestation” tab to be fillable entry cells rather than hard underlined spaces that move/shift as you enter data.
UPL Demonstration Summary	N/A	N/A	N/A	N/A	Updated UPL Demonstration Summary tab to incorporate Medicaid days in the calculations for per diem data.

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Sheet 3: IMD

Sheet	Template Section	Location in Original Version	Location in Current Version	Variable Number	Change since last OMB approval January 2021
Required State Input - IMD	Data	A2	A2	001	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - IMD	Tooltip	A2	A2	001	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - IMD	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	B2	B2	002	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration begin date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	C2	C2	003	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration end date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Data	Column B	Column B	100	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - IMD	Tooltip	Column B	Column B	100	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - IMD	Tooltip	Column C	Column C	101	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration rate year. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are 4 digit numeric strings representing the year in the format YYYY.
Required State Input - IMD	Tooltip	Column D	Column D	102	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the service type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is IMD.
Required State Input - IMD	Tooltip	Column E	Column E	104	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable include "Cost," "Payment," and "Charge."
Required State Input - IMD	Data	Column F	Column F	105	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - IMD	Tooltip	Column F	Column F	105	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the Other State Provider ID Number. A data validation error is triggered when duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E13	E13	105	Updated text for Data Dictionary Long Description: State provider ID number that is not a Medicaid (MCD) ID number (if applicable).
Required State Input - IMD	Data	Column I	Column I	107	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - IMD	Tooltip	Column I	Column I	107	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the State-specific Provider ID (Medicaid ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E15	E15	107	Updated text for Data Dictionary Long Description: Medicaid (MCD) ID number.
Required State Input - IMD	Data	Column J	Column J	108	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - IMD	Tooltip	Column J	Column J	108	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Provider Name. A data validation error is triggered when this variable is missing data or duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - IMD	Data	Column G	Column G	109	Added conditional formatting to flag duplicates of variable 109.
Required State Input - IMD	Tooltip	Column G	Column G	109	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: National Provider ID (NPI). A data validation error is triggered when duplicate values exist for this variable.
Required State Input - IMD	Tooltip	Column K	Column K	110	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the ownership category type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are: Private, NSGO, and SGO.
Required State Input - IMD	Data	Column H	Column H	112	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - IMD	Tooltip	Column H	Column H	112	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Certification Number (Medicare ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E20	E20	112	Updated text for Data Dictionary Long Description: Medicare (MCR) ID number. In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC".
Data Dictionary	N/A	B22	B22	116	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - IMD	Data	D2	D2	116	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Required State Input - IMD	Tooltip	D2	D2	116	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Retrospective or Prospective. A demonstration is retrospective if submitted on or after the start of the demonstration period. A demonstration is prospective if submitted prior to the start of the demonstration period.
Data Dictionary	N/A	B23	B23	117	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - IMD	Data	E2	E2	117	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Required State Input - IMD	Tooltip	E2	E2	117	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the State Plan Amendment Number. Expected format: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Required State Input - IMD	Data	Column L	Column L	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	Column L	Column L	200.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Begin Date for Charge, Cost, or Payment Data. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column L	Column L	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Data	Column M	Column M	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	Column M	Column M	200.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the End Date for Charge, Cost, or Payment Data. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column M	Column M	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	Column O	Column O	212.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustments to Per Diem Charge, Cost, or Payment. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E27	E27	212.3	Updated text for Data Dictionary Long Description: Adjustments to per diem charge, cost, or payment.
Data Dictionary	N/A	E29	E29	215	Updated text for Data Dictionary Long Description: Calculated as Per Diem Charge, Cost, or Payment (Variable 223) + Adjustments to MCR Per Diem Charge, Cost or Payment (Variable 212.3)
Required State Input - IMD	Tooltip	Column N	Column N	223	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Per Diem Charge, Cost, or Payment. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E31	E31	223	Updated text for Data Dictionary Long Description: Per diem charge, cost, or payment used to calculate the UPL from the period specified in Variables 200.1 and 200.21.
Required State Input - IMD	Tooltip	Column P	Column P	300.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column P	Column P	300.1	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E33	E33	300.1	Updated text for Data Dictionary Long Description: Beginning date of base year Medicaid (MCD) days (note: should match charge, cost, or payment or cost data period).
Required State Input - IMD	Tooltip	Column Q	Column Q	300.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Days - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column Q	Column Q	300.2	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E34	E34	300.2	Updated text for Data Dictionary Long Description: End date of base year Medicaid (MCD) days (note: should match charge, cost, or payment or cost data period).
Required State Input - IMD	Tooltip	Column AA	Column AA	307	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Medicaid Inflation Factor Type.
Data Dictionary	N/A	E36	E36	307	Updated text for Data Dictionary Long Description: Description of Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid CD program between the base and current UPL Demonstration rate year periods (e.g., Market Basket).
Required State Input - IMD	Tooltip	Column AB	Column AB	308	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E37	E37	308	Updated text for Data Dictionary Long Description: Cumulative Medicaid CD payment trend factor used to reflect changes in the Medicaid CD program between the base (midpoint of Variables 300.1 and Variable 300.2) and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point approach").
Required State Input - IMD	Tooltip	Column AC	Column AC	309	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustment to Medicaid Payments. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E38	E38	309	Updated text for Data Dictionary Long Description: Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the Medicaid CD program between the base and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point approach").
Required State Input - IMD	Tooltip	Column R	Column R	310	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Days. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E39	E39	310	Updated text for Data Dictionary Long Description: Medicaid (MCD) days from time period specified in Variables 300.1 and 300.2, used in calculating the UPL for the base period.
Required State Input - IMD	Tooltip	Column S	Column S	311.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column S	Column S	311.1	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E40	E40	311.1	Updated text for Data Dictionary Long Description: Beginning date of Medicaid (MCD) rates used to determine total MCD payments for purposes of comparing to the UPL (these dates may differ from period used for days).
Required State Input - IMD	Tooltip	Column T	Column T	311.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Rates - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - IMD	Data	Column T	Column T	311.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - IMD	Tooltip	Column U	Column U	312	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Regular Payment Per Diem. A data validation error is triggered when this variable is missing data.
Required State Input - IMD	Label	Column U	Column U	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
IMD	Label	Column V	Column V	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	D42	D42	312	Changed variable name from “Medicaid Regular Payments Per Diem” to “Medicaid Base Payment Per Diem.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	E42	E42	312	Updated text for Data Dictionary Long Description: Medicaid (MCD) Bbase payments per diem applicable to the time period specified in Variables 311.1 and 311.2.
Required State Input - IMD	Tooltip	Column V	Column V	313.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem. A data validation error is triggered when this variable is missing data.
Required State Input - IMD	Tooltip	Column W	Column W	313.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (GME/Training). A data validation error is triggered when this variable is missing data.
Required State Input - IMD	Tooltip	Column X	Column X	313.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payment Per Diem (Other). A data validation error is triggered when this variable is missing data.
Required State Input - IMD	Tooltip	Column Y	Column Y	314.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #1. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E46	E46	314.1	Updated text for Data Dictionary Long Description: Adjustment to MCD base payments per diem (e.g., drugs, therapy, lab, radiology).
Required State Input - IMD	Tooltip	Column Z	Column Z	314.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Adjustment to Medicaid Per Diem #2. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E47	E47	314.2	Updated text for Data Dictionary Long Description: Adjustment to MCD base payments per diem (e.g., drugs, therapy, lab, radiology).
Data Dictionary	N/A	E48	E48	315	Updated text for Data Dictionary Long Description: Calculated as Total MCD Supplemental Payments Per Diem with Adjustments (Variable 317) + (MCD Base Regular Payment Per Diem (Variable 312) * MCD Inflation Factor (Variable 308) * Other Adjustment to MCD Payments (Variable 309)).
Data Dictionary	N/A	E52	E52	400	Updated text for Data Dictionary Long Description: Calculated as Total Per Diem Charge, Cost, or Payment (Variable 215) * UPL Inflation Factor (Variable 405).
Required State Input - IMD	Tooltip	Column AF	Column AF	401	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Provider Tax Cost. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E53	E53	401	Updated text for Data Dictionary Long Description: For cost-based demonstrations, Medicaid (MCD) provider tax costs can be added to the UPL separately. Report here only the Medicaid MCD portion of the cost of the provider tax.
Required State Input - IMD	Tooltip	Column AG	Column AG	402	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustments to the UPL Amount. A data validation error is triggered when this variable is missing data.
Required State Input - IMD	Tooltip	Column AD	Column AD	404	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter UPL Inflation Factor Type.
Data Dictionary	N/A	E56	E56	404	Updated text for Data Dictionary Long Description: Description of cumulative trend factor used to inflate the Total Per Diem Charge, Cost, or Payment UPL Per Diem Amount from the base year to the UPL Demonstration rate year (e.g., Market Basket).
Required State Input - IMD	Tooltip	Column AE	Column AE	405	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E57	E57	405	Updated text for Data Dictionary Long Description: Cumulative trend factor used to inflate the Total Per Diem Charge, Cost, or Payment Calculated MCD UPL Per Diem from the base year (midpoint of Variable 200.1 and Variable 200.2) to the UPL Demonstration rate year (note: 1.00 = no change) (use "mid-point to mid-point approach
Required State Input - IMD	Tooltip	Column AH	Column AH	408	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Adjustment to the UPL Gap. A data validation error is triggered when this variable is missing data.
Overview & Instructions	Sheet	A5	A5	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – IMD. Updated Overview & Instructions tab to reflect new tab name.
Required State Input - IMD	Sheet	N/A	N/A	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – IMD. Updated Overview & Instructions tab to reflect new tab name.
State Attestation	Data	N/A	N/A	N/A	Modified state data entry fields (dates, names, etc.) on the “State Attestation” tab to be fillable entry cells rather than hard underlined spaces that move/shift as you enter data.
UPL Demonstration Summary	N/A	N/A	N/A	N/A	Updated UPL Demonstration Summary tab to incorporate Medicaid days in the calculations for per diem data.

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Sheet 4: Clinic

Sheet	Template Section	Location in Original Version	Location in Current Version	Variable Number	Change since last OMB approval January 2021
Required State Input - Clinic	Data	A2	A2	001	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - Clinic	Tooltip	A2	A2	001	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - Clinic	Tooltip	B2	B2	002	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration begin date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - Clinic	Tooltip	C2	C2	003	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration end date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - Clinic	Data	Column B	Column B	100	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - Clinic	Tooltip	Column B	Column B	100	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - Clinic	Tooltip	Column C	Column C	101	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration rate year. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are 4 digit numeric strings representing the year in the format YYYY.
Required State Input - Clinic	Tooltip	Column D	Column D	102	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the service type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is Clinic.
Required State Input - Clinic	Data	Column E	Column E	105	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - Clinic	Tooltip	Column E	Column E	105	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the Other State Provider ID Number. A data validation error is triggered when duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E12	E12	105	Updated text for Data Dictionary Long Description: State provider ID number that is not a Medicaid (MCD) ID number (if applicable).
Required State Input - Clinic	Data	Column H	Column H	107	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - Clinic	Tooltip	Column H	Column H	107	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the State-specific Provider ID (Medicaid ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E14	E14	107	Updated text for Data Dictionary Long Description: Medicaid (MCD) ID number.
Required State Input - Clinic	Data	Column I	Column I	108	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - Clinic	Tooltip	Column I	Column I	108	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Provider Name. A data validation error is triggered when this variable is missing data or duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - Clinic	Data	Column F	Column F	109	Added conditional formatting to flag duplicates of variable 109.
Required State Input - Clinic	Tooltip	Column F	Column F	109	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: National Provider ID (NPI). A data validation error is triggered when duplicate values exist for this variable.
Required State Input - Clinic	Tooltip	Column J	Column J	110	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the ownership category type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are: Private, NSGO, and SGO.
Required State Input - Clinic	Tooltip	Column K	Column K	111	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the clinic type. A data validation error is triggered when this variable is missing data.
Required State Input - Clinic	Data	Column G	Column G	112	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - Clinic	Tooltip	Column G	Column G	112	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Certification Number (Medicare ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Data Dictionary	N/A	E19	E19	112	Updated text for Data Dictionary Long Description: Medicare (MCR) ID number. In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC".
Data Dictionary	N/A	B21	B21	116	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - Clinic	Data	D2	D2	116	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Required State Input - Clinic	Tooltip	D2	D2	116	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Retrospective or Prospective. A demonstration is retrospective if submitted on or after the start of the demonstration period. A demonstration is prospective if submitted prior to the start of the demonstration period.
Data Dictionary	N/A	B22	B22	117	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - Clinic	Data	E2	E2	117	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Required State Input - Clinic	Tooltip	E2	E2	117	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the State Plan Amendment Number. Expected format: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Required State Input - Clinic	Tooltip	Column M	Column M	200.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Source Data Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	Column M	Column M	200.1	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E23	E23	200.1	Updated text for Data Dictionary Long Description: Medicare (MCR) fee schedule begin date or cost report begin date that is used to calculate the UPL.
Required State Input - Clinic	Tooltip	Column N	Column N	200.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Source Data End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	Column N	Column N	200.2	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E24	E24	200.2	Updated text for Data Dictionary Long Description: Medicare (MCR) fee schedule end date or cost report end date that is used to calculate the UPL
Required State Input - Clinic	Tooltip	Column O	Column O	203	Added the following tool tip to the data entry cells in the required state input tab: Required if using CCR: Enter Medicare Costs. If variable 224 has a value of "Cost to Charge Ratio," then variable 203 should be populated with data. Leave this variable blank if 224 is either "Payment to Charge Ratio" or "Fee Schedule."
Data Dictionary	N/A	E26	E26	203	Updated text for Data Dictionary Long Description: Base Year Medicare (MCR) or other costs used to calculate the UPL. Leave this blank if using either Payment-to-Charge Ratio (PTC) or Fee Schedule. If variable 224 has a value of "Cost to Charge Ratio," then variable 203 should be population with data.
Required State Input - Clinic	Tooltip	Column P	Column P	204	Added the following tool tip to the data entry cells in the required state input tab: Required if using CCR or PTC: Enter Medicare Charges. If variable 224 has a value of "Cost to Charge Ratio" or "Payment to Charge Ratio," then variable 204 should be populated with data. Leave this variable blank if 224 is using Fee Schedule.
Data Dictionary	N/A	E27	E27	204	Updated text for Data Dictionary Long Description: Base year Medicare (MCR) charges, if using a cost-to-charge or payment-to-charge method, used to calculate the MCR Cost-to-Charge Ratio (CCR) or Payment-to-Charge Ratio (PTC) (Variable 208). Leave this blank if using Fee Schedule. If variable 224 has a value of "Cost to Charge Ratio" or "Payment to Charge Ratio," then variable 204 should be populated with data.
Required State Input - Clinic	Tooltip	Column Q	Column Q	205	Added the following tool tip to the data entry cells in the required state input tab: Required if using PTC or fee schedule. Enter Medicare payments. If variable 224 has a value of "Fee schedule" or "Payment to Charge Ratio," then variable 205 should be populated with data. Leave this variable blank if 224 is "Cost to Charge Ratio."
Data Dictionary	N/A	E28	E28	205	Updated text for Data Dictionary Long Description: Base year Medicare (MCR) payments calculated from MCR fee schedules. Leave this blank if using Cost-to-Charge Ratio (CCR). If variable 224 has a value of "Cost to Charge Ratio" or "Fee Schedule," then variable 205 should be populated with data.
Clinic	N/A	Column R	Column R	208	Updated variable to change from a state-calculated field to template-calculated field. The template automatically calculates the value of variable 208 using the following logic: If 203 and 204 are populated with non-zero values, then 208 = 203 (MCR costs) / 204 (MCR charges)*100%. If 205 and 204 are populated with non-zero values, then 208 = 205 (MCR payments) / 204 (MCR charges)*100%. If 203 and 205 are blank, then set 208 to blank If 203 and 205 are both populated, then set 208 to blank
Clinic	N/A	Column R	Column R	208	Updated the label of variable 208 to MCR Info: (Calculated if using CCR or PTC) Medicare Cost-To-Charge Ratio or Payment-To-Charge Ratio [208]
Data Dictionary	N/A	E30	E30	208	Updated the data dictionary with the following changes: Changed the variable designation for 208 and 400 to “Calculated” instead of “State Calculated.” Changed the long description for 208 to: "For CCR, calculated as MCR Costs (Variable 203) / MCR Charges (Variable 204). For PTC, calculated as MCR Payments (Variable 205) / MCR Charges (Variable 204). This field will be left blank if the source of UPL or Cost Report Data (224) has a value other than Cost-to-Charge (CCR) Ratio or Payment-to-Charge (PTC) Ratio."
Required State Input - Clinic	Tooltip	Column L	Column L	224	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Source of UPL or Cost Report Data. A data validation error is triggered when this variable is missing data. Example values for this variable include Physician Fee Schedule, Cost Report, Cost-to-Charge ratio, Payment-to-Charge Ratio, etc.
Required State Input - Clinic	Tooltip	Column R	Column R	300.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Charge and Payment Data - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	Column R	Column R	300.1	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E34	E34	300.1	Updated text for Data Dictionary Long Description: Beginning date of base year Medicaid (MCD) payment and charge data (if applicable).
Required State Input - Clinic	Tooltip	Column S	Column S	300.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Charge and Payment Data - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - Clinic	Data	Column S	Column S	300.2	Applied conditional formatting if begin dates are not before end dates.
Data Dictionary	N/A	E35	E35	300.2	Updated text for Data Dictionary Long Description: End date of base year Medicaid (MCD) payment and charge data (if applicable).
Required State Input - Clinic	Data	Column T	Column T	301	Applied conditional formatting (red shading) to variable 301 if 301 is missing and: a) 203 and 204 are both populated and 205 is blank or b) 204 and 205 are both populated and 203 is blank
Required State Input - Clinic	Tooltip	Column T	Column T	301	Added the following tool tip to the data entry cells in the required state input tab: Required if using CCR or PTC: Enter Medicaid Charges. An error is triggered when variable 301 is missing data and a) 203 and 204 are both populated with data OR b) 204 and 205 are both populated with data. 301 should be populated when 224 is CCR or PTC.
Data Dictionary	N/A	E36	E36	301	Updated text for Data Dictionary Long Description: Total Medicaid (MCD) Charges for the time period specified in variables 300.1 and 300.2, include if using a Cost, CCR, or PTC method for determining UPL amount. Leave this blank if using Fee Schedule. If variable 224 has a value of "Cost to Charge Ratio" or "Payment to Charge Ratio," then variable 301 should be populated with data.
Required State Input - Clinic	Tooltip	Column U	Column U	302	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Base Payments. A data validation error is triggered when this variable is missing data.
Required State Input - Clinic	Label	Column U	Column U	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Clinic	Label	Column V	Column V	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	D37	D37	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	E37	E37	302	Updated text for Data Dictionary Long Description: Total Medicaid CD non-supplemental payments for base year.
Required State Input - Clinic	Tooltip	Column V	Column V	303.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payments. A data validation error is triggered when this variable is missing data.
Required State Input - Clinic	Tooltip	Column W	Column W	303.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payments (GME/Training). A data validation error is triggered when this variable is missing data.
Required State Input - Clinic	Tooltip	Column X	Column X	303.3	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Supplemental Payments (Other). A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E42	E42	306	Updated text for Data Dictionary Long Description: Sum of all Medicaid (MCD) Supplemental Payments for the expected payment associated with the demonstration year, includes the following variables: (Variable 303.1 + Variable 303.2 + Variable 303.3).
Required State Input - Clinic	Tooltip	Column Y	Column Y	307	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Medicaid Inflation Factor Type.
Data Dictionary	N/A	E43	E43	307	Updated text for Data Dictionary Long Description: Description of Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid program between the base and current UPL Demonstration rate year periods (e.g., Market Basket). If value for variable 308 is anything other than 1.0, then variable 307 should be populated with data.
Required State Input - Clinic	Tooltip	Column Z	Column Z	308	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E44	E44	308	Updated text for Data Dictionary Long Description: Cumulative Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid program between the base (the midpoint of Variable 300.1 and Variable 300.2) and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point approach"). A value less than 1 or greater than 1.04 for this field will trigger an error.
Required State Input - Clinic	Tooltip	Column AA	Column AA	309	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustment to Medicaid Payments. A data validation error is triggered when this variable is missing data.
Data Dictionary	N/A	E45	E45	309	Updated text for Data Dictionary Long Description: Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the Medicaid program between the base (midpoint of variable 300.1 and variable 300.2) and current UPL Demonstration rate year periods (note: 1.00 = no change) (use "mid-point to mid-point approach"). Values of blank or zero will trigger an error for this field. Values for this field should not be negative.
Clinic	N/A	Column AE	Column AE	400	Updated variable to change from a state-calculated field to template-calculated field. The template automatically calculates the value of variable 400 using the following logic: If the value of 400 is calculated as zero or blank, report the value as a zero. If 203, 204, and 301 ALL contain values that are not 0, then 400 = 208 * 301. If 204, 205, and 301 ALL contain values that are not 0, then 400 = 208 * 301. If 205 has a value that is not 0 but 204 is blank, 400 = 205. If 203 and 205 are both blank, then set 400 to zero. If 203 and 205 are both populated, then set 400 to zero.
Clinic	N/A	Column AE	Column AE	400	Updated the label of variable 400 to UPL Calc Info: (Calculated) Medicaid UPL Amount [400]
Data Dictionary	N/A	E48	E48	400	Updated the data dictionary with the following changes: Calculated UPL amount. This will be calculated as described using formulas: If 203, 204, and 301 all contain numeric values that are not 0, then 400 = 208 * 301. If 204, 205, and 301 all contain numeric values that are not 0, then 400 = 208 * 301. If 205 has a numeric value that is not 0 but 204 is blank, 400 = 205. If 203 and 205 are both blank, then the template will set 400 to zero. If 203 and 205 are both populated, then the template will set 400 to zero.
Required State Input - Clinic	Tooltip	Column AD	Column AD	402	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Other Adjustments to the UPL Amount. A data validation error is triggered when this variable is missing data.
Required State Input - Clinic	Tooltip	Column AB	Column AB	404	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter UPL Inflation Factor Type.
Data Dictionary	N/A	E52	E52	404	Updated text for Data Dictionary Long Description: Description of cumulative trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the UPL Demonstration rate year (e.g., Market Basket). If the value for variable 405 is anything other than 1.0, then variable 404 should be populated with data.
Required State Input - Clinic	Tooltip	Column AC	Column AC	405	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the UPL Inflation Factor. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are numeric values from 1.00 to 1.04.
Data Dictionary	N/A	E53	E53	405	Updated text for Data Dictionary Long Description: Cumulative trend factor used to inflate the MCD UPL Amount (Variable 400) from the base year (midpoint of Variables 3200.1 and 3200.2) to the UPL Demonstration rate year (note: 1.00 = no change) (use "mid-point to mid-point approach"). A value less than 1 or greater than 1.04 for this field will trigger an error.
Data Dictionary	N/A	E54	E54	406	Updated text for Data Dictionary Long Description: Calculated as MCD UPL Amount (Variable 400) * UPL Inflation Factor (Variable 405)
Data Dictionary	N/A	E55	E55	407	Updated text for Data Dictionary Long Description: Calculated as Adjusted MCRD UPL Amount (Variable 403) - Inflated MCD Payments to Demonstration Year (Variable 318).
Required State Input - Clinic	Tooltip	Column AE	Column AE	408	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Adjustment to the UPL Gap. A data validation error is triggered when this variable is missing data.
Overview & Instructions	Sheet	A5	A5	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – Clinic. Updated Overview & Instructions tab to reflect new tab name.
Required State Input - Clinic	Sheet	N/A	N/A	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – Clinic. Updated Overview & Instructions tab to reflect new tab name.
State Attestation	Data	N/A	N/A	N/A	Modified state data entry fields (dates, names, etc.) on the “State Attestation” tab to be fillable entry cells rather than hard underlined spaces that move/shift as you enter data.

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Sheet 5: Physician

Sheet	Template Section	Location in Original Version	Location in Current Version	Variable Number	Change since last OMB approval January 2021
Required State Input - PHYS	Data	A2	A2	001	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - PHYS	Tooltip	A2	A2	001	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - PHYS	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Tooltip	B2	B2	002	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration begin date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PHYS	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Tooltip	C2	C2	003	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration end date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PHYS	Data	Column B	Column B	100	Guam, Puerto Rico, and U.S. Virgin Islands were added to the drop down menu as valid values.
Required State Input - PHYS	Tooltip	Column B	Column B	100	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the state. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are two character state abbreviations for the 50 states and D.C.
Required State Input - PHYS	Tooltip	Column C	Column C	101	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration rate year. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are 4 digit numeric strings representing the year in the format YYYY.
Required State Input - PHYS	Tooltip	Column D	Column D	102	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the service type. A data validation error is triggered when this variable is missing data or has an invalid value. The only valid value for this variable in this template is Physician.
Required State Input - PHYS	Tooltip	Column E	Column E	104	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the demonstration type. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable include "ACR" and "MCR Equivalent."
Required State Input - PHYS	Data	Column F	Column F	105	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PHYS	Tooltip	Column F	Column F	105	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the Other State Provider ID Number. A data validation error is triggered when duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PHYS	Data	Column I	Column I	107	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PHYS	Tooltip	Column I	Column I	107	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the State-specific Provider ID (Medicaid ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PHYS	Data	Column J	Column J	108	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PHYS	Tooltip	Column J	Column J	108	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Provider Name. A data validation error is triggered when this variable is missing data or duplicate values exist in the provider information variables. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PHYS	Data	Column G	Column G	109	Added conditional formatting to flag duplicates of variable 109.
Required State Input - PHYS	Tooltip	Column G	Column G	109	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: National Provider ID (NPI). A data validation error is triggered when duplicate values exist for this variable.
Required State Input - PHYS	Data	Column H	Column H	112	Added conditional formatting to flag duplicates across unique combinations of 112, 107, 108, 105.
Required State Input - PHYS	Tooltip	Column H	Column H	112	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter the Medicare Certification Number (Medicare ID). A data validation error is triggered if data are missing or duplicate values exist in the provider information. The combination of values for variables 105, 112, 107, 108 must be unique.
Required State Input - PHYS	Data	D2	D2	116	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B21	B21	116	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - PHYS	Tooltip	D2	D2	116	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter Retrospective or Prospective. A demonstration is retrospective if submitted on or after the start of the demonstration period. A demonstration is prospective if submitted prior to the start of the demonstration period.
Required State Input - PHYS	Data	E2	E2	117	Changed variable designation status from Required to "PIA". Removed conditional formatting when this field is missing data.
Data Dictionary	N/A	B22	B22	117	Data dictionary updated to reflect variable designation status changed from Required to "PIA."
Required State Input - PHYS	Tooltip	E2	E2	117	Added the following tool tip to the data entry cells in the required state input tab: Provide if applicable: Enter the State Plan Amendment Number. Expected format: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Required State Input - PHYS	Data	Column K	Column K	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Tooltip	Column K	Column K	200.1	Added the following tool tip to the data entry cells in the required state input tab: Required if Medicare Equivalent of ACR Approach: Enter the Time Period of Medicare Rates Begin Date. A data validation error is triggered when Demo Type (104) is "MCR Equivalent" and this variable is missing data or has an invalid value.
Required State Input - PHYS	Data	Column L	Column L	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Tooltip	Column L	Column L	200.2	Added the following tool tip to the data entry cells in the required state input tab: Required if Medicare Equivalent of ACR Approach: Enter the Time Period of Medicare Rates End Date. A data validation error is triggered when Demonstration Type (104) is "MCR Equivalent" and this variable is missing data or has an invalid value.
Required State Input - PHYS	Tooltip	Column M	Column M	225	Added the following tool tip to the data entry cells in the required state input tab: Required if Medicare Equivalent of ACR Approach: Enter Medicare Payment Amount. A data validation error is triggered when Demonstration Type (104) is "MCR Equivalent" and this variable is missing data. Leave this variable blank if 104 is "ACR."
Required State Input - PHYS	Tooltip	Column N	Column N	226	Added the following tool tip to the data entry cells in the required state input tab: Required if Medicare Equivalent of ACR Approach: Enter ACR as Percent of Medicare Rate. A data validation error is triggered when Demonstration Type (104) is "MCR Equivalent" and this variable is missing data. Leave this variable blank if 104 is "ACR."
Required State Input - PHYS	Tooltip	Column O	Column O	300.1	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Payment Data - Begin Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PHYS	Tooltip	Column P	Column P	300.2	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Time Period of Medicaid Payment Data - End Date. A data validation error is triggered when this variable is missing data or has an invalid value. Valid values for this variable are dates in the format MM/DD/YYYY.
Required State Input - PHYS	Tooltip	Column Q	Column Q	302	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Regular Payments. A data validation error is triggered when this variable is missing data.
Physician	Label	Column Q	Column Q	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Required State Input - PHYS	Label	Column Q	Column Q	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Data Dictionary	N/A	D31	D31	302	Changed variable name from “Medicaid Regular Payments” to “Medicaid Base Payments.” Changed variable label and tool tip on required state input tab, output tab, and updated data dictionary to reflect the change.
Required State Input - PHYS	Tooltip	Column R	Column R	304	Added the following tool tip to the data entry cells in the required state input tab: Required: Enter Medicaid Volume of Services. A data validation error is triggered when this variable is missing data.
Required State Input - PHYS	Tooltip	Column S	Column S	420.1	Added the following tool tip to the data entry cells in the required state input tab: Required if ACR Approach: Enter Time Period of Commercial Rate Data Begin Date. A validation error is triggered when Demo Type (104) is "ACR" and this variable is missing data or has an invalid value. Leave this field blank if 104 is "MCR Equivalent."
Required State Input - PHYS	Tooltip	Column T	Column T	420.2	Added the following tool tip to the data entry cells in the required state input tab: Required if ACR Approach: Enter Time Period of Commercial Rate Data End Date. A data validation error is triggered when Demo Type (104) is "ACR" and this variable is missing data or has an invalid value. Leave this field blank if 104 is "MCR Equivalent."
Required State Input - PHYS	Tooltip	Column U	Column U	422	Added the following tool tip to the data entry cells in the required state input tab: Required if ACR Approach: Enter Average Commercial Rate (ACR). A data validation error is triggered when Demonstration Type (104) is "ACR" and this variable is missing data. Leave this variable blank if Demonstration Type (104) is "MCR Equivalent."
Required State Input - PHYS	Tooltip	Column V	Column V	423	Added the following tool tip to the data entry cells in the required state input tab: State Calculated: Enter Enhanced Payment Amount.
Required State Input - PHYS	Data	B2	B2	002	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Data	Column K	Column K	200.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Data	Column O	Column O	300.1	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Data	C2	C2	003	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Data	Column L	Column L	200.2	Applied conditional formatting if begin dates are not before end dates.
Required State Input - PHYS	Data	Column P	Column P	300.2	Applied conditional formatting if begin dates are not before end dates.
Overview & Instructions	Sheet	A5	A5	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – PHYS. Updated Overview & Instructions tab to reflect new tab name.
Required State Input - PHYS	Sheet	N/A	N/A	N/A	Changed tab name for required state input from “Required State Input” to: Required State Input – PHYS. Updated Overview & Instructions tab to reflect new tab name.
State Attestation	Data	N/A	N/A	N/A	Modified state data entry fields (dates, names, etc.) on the “State Attestation” tab to be fillable entry cells rather than hard underlined spaces that move/shift as you enter data.